Radical Surgery.

Joseph Califano Times Books, $25 By Harris Wofford 

The failure of the 103rd Congress to take even the first steps in health care reform left a void in a vital national debate. With a punchy, provocative, and enlightening new book entitled Radical Surgery, Joseph Califano, former secretary of Health, Education, and Welfare, helps fill that void. In 316 pages of short bursts of simple but often contradictory truths about what he calls our "sick care" system, Califano outlines the problems that plague American health care and points towards a solution.

Halfway through, the book seems maddeningly repetitive. Califano makes the same basic points again and again. Open the book to any page, and Califano's fundamental prescriptions leap out at you. But there's a method in this madness. After enough doses of this medicine, delivered in vivid language, with striking new statistics or personal anecdotes, Califano's prescriptions begin to do their work.

We see Califano's 92-year-old demented mother, with kidney failure, who had been promised by her son not to be sent to die in a hospital, but whose doctor intended to hospitalize her for dialysis and other "heroic" measures to prolong her life. Her son said, "She's ready for God," and took responsibility for letting her die at peace in her own bed, with her husband holding her hand.

Two hundred and twenty-eight pages later, there are the stories of Richard Nixon and Jacqueline Kennedy Onassis, each having signed a living will, declining the use of medical machinery to postpone imminent death. Califano hopes that the grace and dignity with which Jackie died will have even more lasting influence on American social customs than the courage she displayed when John Kennedy was assassinated. Califano tells of the brave old Polish Cardinal Wyszynski who said from his sickbed, "There are too many machines and tubes and wires," and asked if United States doctors were sensitive to "the need for one person to touch another."

Califano rails at the bureaucratization of modern medicine, which leaves little time for touching. "What we need from our doctors is less of this new T.L.C.--technology, lasers, and cat scans--and more of the old T.L.C.--tender loving care--grounded in a basic respect for human dignity." He sees that the central truth that the practice of medicine is "a sacred calling, not a for-profit enterprise," is "being choked in the thick underbrush of regulatory and insurance reimbursement rules and crushed in the machinery of modem hospital centers."

Califano knows these modem centers are vital for life-saving and for research but he believes that they, along with the doctor-patient relationship and all the best of American health care, have never been in such peril. The trillion-dollar health care industry, now nearly one-sixth of the nation's economy, is in "portentous turbulence," with doctors, hospitals, health maintenance organizations (HMOs), insurance carriers, and pharmaceutical companies reshaping health care, scrambling into mergers and networks, cooking up new delivery systems, and mounting aggressive marketing campaigns.

The good news Califano draws out of the 1994 health care reform fiasco is the emergence of a political consensus that all Americans should have timely access to care. The bad news is that the debate showed that Murphy's Law was written with America's health care reformers in mind: "Silver Bullet" health care legislation, Califano argues, is doomed to failure.

Califano writes from experience. He confesses his own miscalculations in tinkering with American health care in the sixties and seventies--from his work in Lyndon Johnson's White House as they created Medicaid and Medicare, to leading Jimmy Carter's Department of Health, Education and Welfare. He renounces his earlier obsession with the financing and delivery of care for the sick, and now would have us emphasize health promotion and disease prevention. He points to the pandemic of substance abuse and addiction, the aging of our population, and the rush of technological innovation as the triple-threat to any serious attempt to restrain health care costs.

Throughout this book, the contradictions of Califano's case are showing. On the one hand, this former formidable Washington policy wonk attacks Beltway mentality. "No one," he writes, "is smart enough to write a single law to revamp the entire health care system." Having worked with the health care industry as a private lawyer, as a member of Chrysler Corporation's board, and as founding president of Columbia University's Center on Addiction and Substance Abuse, he's been "increasingly struck by the limits of legislative fixes." He argues that "cultural attitudes that influence individual behavior offer greater opportunities to curb costs and increase access than all the laws, regulations, financing gimmicks and theories of the policy wonks sitting in Washington."

Yet after listing a number of the cultural factors that affect our health care system--seat belts, divorce, guns, beer, tobacco, food, poverty, violence, sex, lousy parents--Califano recommends a slew of laws. His prescription includes: stringent gun control legislation; taxation of cigarettes to the point that they are too expensive to be purchased by children; prohibition of vending machines and stiff penalties for sale to minors; similar restraints on the sale and advertising of alcohol; and, above all, campaign finance reform which, he says, will limit the political influence of the health care industry. Califano also calls for the extension of Medicare to all the poor; community-rated insurance premiums; assured coverage regardless of preexisting conditions or employment status; guaranteed portability from job to job; and mandated employer coverage of all employees.

Despite Califano's numerous contradictions, it would be wrong to conclude that he ties himself in a knot. Fundamental campaign finance reform may be as far away as a Congressional majority for an employer mandate to provide health insurance. But Califano's voice of experience, if heard well, could help us move to the next steps. The contradictions in his case are the very contradictions in the system that make reform so difficult. He conveys this complexity not as an excuse for doing nothing, but in order to show how much there is to do.

Human conduct, Califano says, not legislative legerdemain, is the crucial key. The private institutions and governments performing the radical surgery necessary "must use their scalpels with painstaking delicacy in order to preserve and enhance the intimacy and integrity of the doctor- (and nurse-) patient relationship, which is the aorta of any effective system."

"Delicacy" may be too much to ask of the rough-and-tumble mix of politics and money that Califano predicts will prevail in the next decade of health care reform. What Califano asks from the political world are "sensible laws, aimed at the right targets, mandating, encouraging and nourishing individual and institutional conduct that will move the nation toward universal coverage at affordable cost."

But beyond laws, what Califano seeks is a cultural revolution to change the way American individuals and institutions view health. He suggests that the place to start hammering out a technological morality for American medicine is with the American way of death. And the most vital questions of life and death must be reserved to the people.

"The radical surgery that lies ahead," writes Califano, "is too important to be left to the best and the brightest politicians, physicians, and policy gurus. Each of us must be prepared to take a scalpel in hand."

With this fine book, Califano has done his part. Harris Wofford is a former Senator from Pennsylvania.